11 predictions for the health-care reform bill

I'm a little confused by this post Megan McArdle has written saying that I refuse to make testable predictions regarding the eventual impact of health-care reform. As I told her in the e-mail exchange that led to her post, I believe that by 2030 we will have "peer-reviewed research" that will have quantified at least tens of thousands of lives saved. As research tends to take a few years to collect, I expect that will only cover about 10 or 15 years of the bill. To quote again from my part of the e-mail, I believe we will have research showing that this law "prevent[ed] a hundred thousand insurance-amenable deaths within 30 years of full operation."

The point about research is important. If McArdle wants to do testable predictions, let's do them right. That's why I chose 30 years: It takes some time to gather good data on this stuff. But to be more specific, I think that the research will show that the bill did that between 2019 and 2039, if not much sooner. (By the way: an insurance-amenable death is something like a stroke, where we know the insured have much better chances of surviving than the uninsured).

I don't think that's exactly ducking the question. It seems like a testable prediction to me. And I'll make a few more:

1) The excise tax will go into effect on schedule, but it might be indexed to inflation plus one (or even two) percentage points, rather than just inflation.

2) The Medicare cuts will also go into effect with very few, if any, changes.

3) There will be at least one policy in the bill that will be a very effective cost control but that we're not thinking of. One contender for this is the provision penalizing hospitals with high infection rates, which could save quite a lot of money in terms of readmission and recuperation costs if it's effective.

4) There's a very good chance that the difference between the bill's spending and its cost controls/revenues/reforms will prove greater than what the Congressional Budget Office is predicting. To make this a bit clearer, I think there's at least a 60 percent chance that the bill saves in excess of $1.5 trillion between 2020 and 2029.

5) This policy will be very popular in 10 or 15 years. The GOP will not talk of repeal, and will instead argue that they will do a better job administering the health-care system than Democrats.

6) Premiums will grow more slowly inside the exchanges than has been the historical average for the individual and small-business markets.

7) There is a chance -- say, 30 percent -- that the Independent Payment Advisory Board (the Medicare commission) becomes an extremely, extremely important government body.

8) There will be significant supplementary reforms by 2018.

9) Most Americans will not find America to be a substantially more tyrannical, totalitarian or socialist country come 2020. The frenzy over this bill will be something people quote to discredit future frenzies, not to give added weight to tomorrow's hysterical predictions.

10) There will be strong evidence that this bill led to important quality improvements in medical care, particularly in terms of hospital-acquired infections and cost-effectiveness of treatments.

I know you're buddies, but be honest: Has Megan McArdle ever demonstrated that she had the first frigging clue about the health care bill, or health care in general? She just swings wildly from one unsupported assertion to another.

For Megan's sake, give her a few days to cool off. She made some predictions about HCR reforms likely passage, they went wrong relatively quickly, and now she's throwing some hissy fits (much like the Republicans party, currently).

Seriously, just give her a minute to recover, and then go back to treating every tenth thing she writes seriously. Every once in a while there's an interesting, contrarian point in her work, but for the love of God she prints a lot of crap.

These aren't your daddy's era hippies; today's statist lefties would have scoffed at the notion of any government mandate that they buy anything; hippies would be burning their health insurance cards; times, they are a' changin'....

These aren't your daddy's era hippies;those hippies would have scoffed at the notion of any government mandate that they buy anything; they'd be burning their health insurance cards; not today's statist Lefties, though, who seem to eat this command and control stuff up; times, they are a' changin'....

"I believe that by 2030 we will have 'peer-reviewed research' that will have quantified at least tens of thousands of lives saved"

I hate to be a broken record, but I think that needs to be clarified. People are not immortal. Lives are not saved in perpetuity. In fact, I don't think it's accurate to talk in terms of "lives saved" at all, but of "lives extended". And how much extra life, on the whole, will those tens of thousands of people enjoy? Three days? Three weeks? Three months? Three years?

These aren't irrelevant questions. Blanket assertions that there will be "thousands of lives saved" don't really provide meaningful information. Thousands of lives saved that die the next week or the next month are something, but much less than thousands of lives saved that lead into extensions of lives by 5 or 10 years.

Apart from that, for me - Ezra, job well done. You are ready to make those predictions which will be testable.

Go man go, you have to lead the charge at every new challenge these regressive thoughts and thinkers throw at us (even if they themselves never apply those standards to GOP; for example, have you ever heard 'testable' predictions about the great lunatic theory of 'tax cuts for prosperity'?).

I take your point, but I think it is kinda nit-picky. To follow your logic, it is a bit like saying that Hitler did not kill 6 million Jews, he simply reduced their lifespans, since nobody is "immortal." Or that a lifeguard did not save a life by preventing a drowning, he or she just made it go on longer.

If there is more early detection and intervention, more people will avoid an untimely demise. Some will be old, some will be young, some will be in-between. Their lives will be saved.

I don't know why Ezra bothered to take the bait and make predictions. Predictions are stupid. It's just a way to make it seem like you are smarter than you are. You don't need to prove anything to Megan or anyone else.

I don't read Megan but is there a reason that you give HCR credit for medical advances? Haven't medical advances happened in the past 100+ years WITHOUT HCR in the USA?

Also another word that's not mentioned above (TAX) If the cost controls don't end up doing much you could always tax people more.

In conclusion I disagree with points (1, 2, 4,6 STRONGLY, 10).

In regards to point 6 (premiums growing more slowly in the exchange) how do you see that? The exchange is nothing more than the individual market on steroids with a weak mandate to TRY to keep everyone in as well as mandated levels of benefits which are HIGHER than most state's current requirements (with mine of NJ probably ending up an exception to that rule). The only plus to the "reducing costs side" which really isn't reducing costs just shifting it are the subsidies.

ALso there's no way large employers (especially those with income earners over the subsidy level) participate in the exchange. ERISA law not applying keeps costs down outside of the exchange and UP inside of it.

Ezra, this prediction: "I believe that by 2030 we will have peer-reviewed research that will have quantified at least tens of thousands of lives saved".

It sounds like what you were predicting before, but it isn't necessarily. The studies you quoted before found that between 15,000 and 45,000 die every year because they do not have health insurance, and that they would not have died otherwise. But suddenly you are predicting this bill, which extends coverage to more than 70% of the uninsured, will only save 'tens of thousands' of lives over more than ten years. That could be as little as 2,000 a year out of the 15,000-45,000.

Why the disparity? Do you think a disproportionate number of those deaths is among illegal immigrants, for instance, who won't be covered by this bill? Or are you simply not as confident about the bill's effects as you were when citing those studies?

visionbrkr:
Slower premium growth in the exchanges versus the employer market is a test of what used to be a core conservative principle: that individuals, empowered to purchase their own health care, can make better choices and apply market pressure better than third parties like the government or employers.

Over time, this has evolved into a technocratic, non-partisan argument that employers do not exert significant pressure on insurance cost growth since they can hide cost growth by reducing growth of wages. Since it is difficult for a worker to assess what wage increase he/she should have gotten had HC premiums not grown as much as it has (even the verb tenses are confusing), no is keeping an eye on insurance costs unless they're arbitrary and enormous as we recently saw with Anthem.

A key compoment of the bipartisan Wyden-Bennet bill was empowering individuals to make HC purchases rather than third parties. Many of us hope that demonstrating that individuals can indeed effectively make purchasing decisions better than their employers will be the final nail in the employer-based health care coffin, and that the law just passed will eventually result in a Wyden-Bennet like system.

Adding mandated minimums may make insurance appear to cost more (though saying it really does cost more is tricky since you can't compare minimally mandated insurance to cheap junk insurance on an apples-to-apples basis, they're not the same product), but it shouldn't impact cost growth since the mandates don't change over time.

Hey Kevin, claims could be made about the standardized mortality rate, but no one knows what that means. If life spans are on average 1 year longer with HCR, then 1 80 year old "life" was saved for every 80 people in the new system. If the public can't even tell if death panels are real, how do you think such a subtle argument would go over?

I love Wyden Bennett but this isn't it. Its a half-hearted attempt to get there and as I said cost will have employers staying out of the exchange because ERISA saves employers a lot of money through the lack of mandates and then self-insurance on top of that also reaches efficiencies that the exchange can't. I don't expect Aetna to for example have one network of pricing with docs inside the exchange and one outside.

As far as mandated minimums it would depend on how far away current benefits and in turn costs are from the mandated minimum. If benefits are drastically better then costs are drastically better (as this assumes no price controls).

I predict that in 20 years Megan will start from a false premise, grudgingly accept a few points that are beyond dispute, assume the worst-case scenario, and then pass judgement based on that worst-case scenario. Then, act indignant at anyone who doesn't agree with her worst-case scenario conclusions.

I'd add one prediction. In 30 years Republicans will have recycled the exact same nonsensical talking points/hate speech they used against HCR at least once, and probably twice. They will claim some harmless law that helps unfortunate people is Armageddon, that it is tyranny, that it will be the downfall of America, etc etc.

We saw these talking points with Social Security, Medicare and the Clinton budget. They won't go away; they will just be aimed at other harmless pieces of legislation.

Lee_A_Arnold is right with respect to productivity. The existing system has extremely distortive effects on people's job choices, mobility, etc. I have a friend who wants to move from one state to another, and it would be a great move for his career. But he can't because he has an expensive preexisting condition, and the insurer he's with doesn't sell coverage in NY, where he wants to move. One thing to predict is a boost to general productivity as people stop having to make career decisions for these ridiculous reasons.

Ezra, you did dodge her question although it was tough to answer. Her point was that statistics like average life expectancy, 45,000 uninsured deaths a year and bankruptcy percentages have been used as support for this bill. She wants you to honestly say that either all of these statistics will show measurable improvement or that they were all BS. So, do you think these statistics will improve and when and by how much?

When the Democrats were supporting strong cost controls last summer she made the audacious claim that any cuts in pharma profits would cut the growth in average lifespan worldwide by a factor that would compound annually.(ie an exponential rate)

Now that the Democrats have heeded her specious arguments and passed a plan that will increase pharma profits significantly, do we see her claiming that average lifespans around the planet are about to start trending upward dramatically? Nope, Megan has decided to put last summer's credulity aside in exchange a position of comical skepticism.

Doing a rough calculation using the numbers that Megan cites, this healthcare bill will promote the development of new drugs that will extend average lifespan around the planet by about 2 years for every 50 years that the plan is in effect. And this doesn't even consider the benefits of people actually having access to healthcare. This is the benefit purely from the fact that we're giving PHARMA more money!

Summary: Megan McArdle is the Chief Apparatchik of the Concern Troll Division of the Republican Propaganda Machine.

I suppose it's not measurable, but I wish people would acknowledge the great good the bill will do in easing a lot of stress and anxiety in the lives of those who are inadequately insured or uninsured. There's a reason why people in nations with universal coverage report high satisfaction with their systems, even if it comes at great cost. The benefits of knowing that you're not one accident or as-yet undiagnosed condition from being a slave to bills for the rest of your life are intangible. The lessening of the incredible stress of doing all the paperwork, the infuriating phone calls, the back and forths with doctors and insurers, etc. to actually getting insurance company's to comply with the guarantees they've made--I don't know how you put a price tag on that but. But from personal experience, it's pretty high.

Seems to me the research on saving lives is going to be very difficult. Today you could assemble panels of people matched on most characteristics except one panel has insurance and one does not. But in 2020 that's going to be very difficult, because there's no uninsured people, or at least not many. So the best you can do is say "what if"--here's an obese 25 year-old in 2015 who develops diabetes in 2020 and dies in 2030 despite medical care but if he didn't have insurance he would have died in 2025. Not my idea of solid proof.

Erza,
With all due respect, what time period did you have in mind when you declared on 12/14/09 that "Joe Lieberman seems willing to cause the deaths of hundreds of thousands of people in order to settle an old electoral score"? The study you linked to when making that claim calculated that "137,000 people died from 2000 through 2006 because they lacked health insurance." Can you please explain why you are now only willing to predict that “by 2030 we will have ‘peer-reviewed research’ that will have quantified at least tens of thousands of lives saved”? I don't want to falsely assume that you now doubting the methods used in that study, but that seems like the most logical answer.

What is it about blogging/political commentary that demands this kind of chest thumping over who is making predictions or not?

Andrew Sullivan is over at his place fessing up to his bad predictions in February about HCR being dead. Why'd he feel like he had to call it dead before anyone knew WTF was going on? And more, what good does it do anyone to use such a big platform to pull those kinds of pronouncements out of one's... well, you know?

And here you seem to feel goaded into making predictions or somehow you're standing down or shirking your responsibility.

This pressure to make predictions seems like some kind of rooster strutting going on in the blogosphere. I'm not clear what social purpose it serves.

Isn't it enough to analyze what we have in front of us? Or to perhaps IMAGINE potential predicaments that might unfold given what we know now?

But this kind of crystal-ball-gazing seems like a real waste of brain cells. And the tone of your response has a "see, I can too make predictions." But I mean, who cares, right? These kinds of laundry lists filled with vague adjectives don't seem helpful in advancing any kind of understanding of health care reform policy. IMHO.

I mean, a sentence like this: "I think there's at least a 60 percent chance that the bill saves in excess of $1.5 trillion between 2020 and 2029" or this "There is a chance -- say, 30 percent -- that the Independent Payment Advisory Board (the Medicare commission) becomes an extremely, extremely important government body"-- what good does that do anyone? It's a lot of vague hand-waving.

I'll bet there's one policy that is very ineffective and has the potential to bankrupt hospitals: the policy that prevents unauthorized immigrants from buying health care on the exchanges. Considering that immigration reform is probably dead in the water and that the number of immigrants coming to this country is likely to increase, this is likely to become a very big problem and the Joe Wilson's of the world will have to stuff it and let the appropriate policy changes go through.

'frankle' and many other commenters, you may want to read Karl Popper and Falsification criteria.

It has nothing to do with 'blogging'.

Megan is right here trying to pull Ezra in making predictions and Ezra is right here in obliging her.

The theory is any scientific statements should be provable to be wrong. If not, it is a platitude. Core thesis of Ezra wonkery and Economics is, it is Science or at least a rational discourse. Meaning proponents take 'responsibility' for their arguments and their theory.

That is why it is right for punditry to stake out the neck and make predictions.

Beyond that, don't worry that if predictions are wrong means punditry is wrong and it did not serve readers. No, even Einstein got things wrong. Idea is when you make many of these predictions, it will help to validate the theory behind those and collectively our knowledge gets validated, vindicated and we progress. (No small reason why Progressivism and Science go together so much and Conservatism is fundamentally inclined to assume the primacy of central, immutable Truth.)

So, again, Ezra, be bold; don't hesitate in predictions and as a result in taking responsibility. Leadership, intellectual or political or otherwise, is always about carrying the 'cross' of your arguments and thoughts.

ezra - even though i didn't want the HCR bill to pass (as it was written), I hope many of your predictions come true. that said, the only ones I agree with you on are: 5 and 9 - which to me are highly correlated with each other. The other predictions seem more like wishful thinking.

And the peer-reviewed research prediction is a little weak. Someone, somewhere will produce a study saying anything. Be more concrete.

With all due respect, I have read Karl Popper and a wad o' critiques of Karl Popper, and I understand falsification...in a context of systematic scientific inquiry, but we could argue a long time about whether health care reform policy can be subject to that kind of investigation.

In any case, Ezra Klein, as far as I can tell, is not a scientist conducting scientific inquiry. This is Ezra Klein:

"Ezra Klein writes an opinionated blog on economic policy, collapsing banks, cap and trade, health care reform and pretty much anything else you can attach a chart to. His blog points to the hottest policy ideas on the Web and provides his own up-to-the-minute take. Before coming to The Post, he was an associate editor at the American Prospect. Klein has appeared as a guest on CNN, MSNBC, NPR and C-SPAN and lots of online radio shows you've never heard of.

Klein, who makes a mean kung pao, will also be a regular contributor to The Post's Food section. He contributes to the group food blog the Internet Food Association."

Why is someone like Ezra Klein, who is "an opinionated blogger" with no "science" credentials expected to produce predictions that can be experimentally verified or falsified?

It seems to me this kind of conflation of "science" and "opinionated blogging" generates more confusion and unrealistic expectations than if we more or less stuck to our actual skills.

I don't believe rational discourse is subject to anything like falsification criteria. I think you can engage in a lot of rational discourse (and disagreement) over what we see right in front of us -- and take responsibility for our analysis and opinions -- without making crystal ball pseudo-scientific predictions.

'frankle' if you were to say Megan's blog as opinionated; I would readily accept...

For sure Ezra is not doing Quantum Electrodynamics or String Theory. But he and so many of social theory folks are trying to emulate the model of 'physical science'. That is the precise reason there is so much of a backlash on Econometric Theories (all mathematical model but no 'cattle') after the financial chaos of 2008 and so much of Behavioral Economics of Shiller, Kaheman and gang is getting attention.

Rational discourse without attesting to any verifiable propositions, what good it is off? Sure, Ezra is bit entertaining but you do want reading of his blog nothing more than some kind of 'intellectual ma*turba**on'? I am not ready to waste my time like that for the same reason I am least interested in reading Op-Ed by a Politician.

This post illustrates perfectly how the intellectual debate over HCR is going to go down. People on both sides are going to make claims about what would have happened under the status quo. But it will not be an equal fight because reform is going to spawn a cottage industry of wonk-pundits and other experts who justify their existence by defending HCR. Herodotus would be proud.

'bmull' did you dare to say Ezra is the cottage industry of HCR? Oh, common; he can write about 'food scene in DC'. Besides he loves Santa Cruz, our neighbor in Bay Area. So he is good, he is not making living only on HCR.

On second thought, I like it that he is making the living off HCR. Until and unless this country has such dedicated 'wonks' fully supported, we will not get the change. Otherwise I do not want to see him 'David Frum' pulled on him.

It's nice to see that young people like Ezra are still full of enthusiasm and naive beliefs about progress. I held many of those beliefs when I was his age, before my ideals collided with reality. He was probably in daycare when HMOs were invented by Paul Ellwood to accomplish what Obamacare promises. The idea was that prevention was going to save thousands of lives. People were going to flock to doctors' offices for preventive care and lifestyle advice. Many people enrolled in these low cost plans, which were eagerly welcomed by administrators of public assistance plans. Finally something was going to be done to help all those folks whose lower economic status and lack of access to health care had to be the only cause for their bad health outcomes. Well, of course, it didn't turn out that way. People joined HMOs mainly because the premiums were lower and they thought they could get Cadillac care for VW prices. When they learned that wasn't the case, they tried to raise hell. Poor people continued to have bad health ouitcomes, so lots of studies were comissioned by people like Ezra and it turned out that the bad outcomes were due to racist attitudes of doctors, not bad choices by the patients. Oh yeah, and doctors made all kinds of mistakes, killing 100,000 patients a year, never washing their hands and letting lethal infections run rampant through hospitals. Infections caused by super bugs created by over prescribing antibiotics to unsuspecting patients.
I have no doubt that future peer reviewed studies will support Ezra's predictions. I am confident at the 95% level. This is because there is no control group, no alternate universe where we can see how things would have turned out if we hadn't spent 1 or 2 or e trillion dollars. We will have to rely on models, the models already cooked up and parameters loaded into the programs that will show beyond a shadow of a doubt that even though individual crank doctors like me will still observe patients living their lives the way they want to, they will, on average, live 1.2 extra years. And did I mention that it will be peer reviewed?
Here's my take on things, all sarcasm aside: prosperity produces better health outcomes. That and cultural practices. So in prosperous but culturally backward locations, health suffers. We'll continue to have to play the race card to blame physicians for bad health outcomes if the peer reviewed studies stumble a bit. We'll still have the models to reassure us that things would be oh so much worse without all the wealth transfer. Unless the current administration continues to fumble the ball regarding economic recovery and makes the same mistakes the last administration made regarding home ownership along with its continued attempts to push free enterprise outside the borders of the US and keeps demonizing the engine of capitalism.

1. Unions will not allow the excise tax to be indexed at inflation plus 1% if they aren't able to stop it from being implemented completely.

2. Medicare, like all health entitlements, is a radioactive issue and very resistant to cuts. Both voters and industry would be solidly against the cuts.

3. I clicked on this link knowing that you would be cheerleading. You are an intelligent and informed individual, but I often read your posts and can't figure out why you think the way you do. Is the "there will be some part of this that is effective, we just aren't sure what" a good argument. I am willing to wager that for every cost-cutting measure that performs better than expected, there will be five measures that are more expensive than expected.

4. I don't see any evidence to believe this. Almost all cost-cutting measures and expectations are based on unlikely contingencies concerning future congressional votes, market prices, and GDP growth.

5. Agreed. This is a common element of just about any entitlement program. The question is whether this is good, with government and the people on the same page, or if this ends up with rioting like in Greece where the people are fighting the cuts government finds it necessary to make.

6. How is this possible with the vast divide in subsidies between the exchanges and employer provided insurance markets?

7. I would say 30% chance of it becoming important is a possibility, effective is another story.

8. Not much a prediction there.

9. The worry over creeping totalitarianism is only prevalent among the extreme right (and I suppose the extreme left, considering the corporatism in this bill), and it is the spending that is really worrying people. I say the probability of health care spending being a far greater problem in 10 years might reverse your prediction.

10. Studies show that the insurance plans that we are pushing through now hurt cost effectiveness, and that the high deductible insurance plans that do lead to greater cost effectiveness are outlawed.

I think #3 is wrong just because the hospitals will simply pay the slap-on-the-wrist fines for infections, because hospitals make mega bucks on infection-related repeat business. In fact, I think the reason they DON'T try to get rid of infections is BECAUSE it gives them more business. They probably even try to create new ones for more business. Don't go into a hospital unless you plan on getting a hard-and-expensive-to-treat infection. I've heard way to many stories of insured people going in with a sprained ankle and subsequently being hospitalized for months for a staph for it to be just "anecdotal".